Patient Safety

TapRooT® Root Cause Analysis for Patient Safety

TapRooT® does what common root cause analysis fails to do.

Lucian Leap published “To Err is Human” in 1999 and provided the shocking estimate that up to 98,000 Americans die each year as a result of medical errors. Despite efforts to improve patient safety, including attempts using basic root cause analysis tools in the healthcare setting, these numbers of deaths are now estimated to be even higher – perhaps 200,000 people per year die or are significantly injured because of mistakes made during care. What can patient safety professionals do to make significant improvements in patient safety and the quality of care? To start with, health care professionals can adopt best practices from other industries that have been proven to improve human performance. This includes advanced root cause analysis – TapRooT®.

But TapRooT® isn’t completely new to the healthcare field. The Military Healthcare System adopted TapRooT® to use around the world. Other hospitals have been applying TapRooT® successfully to their sentinel event investigations. And The Joint Commission accepts TapRooT® Investigation Reports as part of their voluntary reporting program. See one of the healthcare success stories from an actual user to the left.

Why not test TapRooT® at your facility and see how much improvement you can achieve?

Challenges:

Eliminating “never events.”

Stopping sentinel events.

Improving human performance in the complex hospital care environment.

Explaining the causes of sentinel events to doctors and hospital administrators.

Improving patient care.

Reducing staff injuries.

Reducing hospital acquired infections.

Achieving outstanding accreditation and Leap Frog ratings.

Reducing malpractice insurance costs and minimizing errors that result in lawsuits.

PATIENT SAFETY SUCCESS STORY

Our challenge was to effectively investigate incidents under our new “non-punitive environment” policy. We chose to use TapRooT® to find fixable root causes rather than placing blame.

The first incident investigated using TapRooT® was one that, in the past, would probably have been very blame oriented. The wrong patient was given the wrong drug intravenously. This action violated out “5 Rights” policy. By using TapRooT® we found causes beyond “the policy was violated” that led to the following improvements:

• Increasing the type size printed on the IV labels

• Printing the patient’s name in BOLD letters

• Lowering the height of the IV bags delivered by pumps

Introducing these changes did not reduce the emphasis on the “5 Rights.” The corrective action highlighted that hospital management was taking action to ensure the “5 Rights” policy could be implemented consistently and accurately. Therefore, in addition to effective corrective actions, TapRooT® helped:

• Find root causes that we previously would have overlooked.

• Complete an investigation without blame and discipline.

• The staff will be more willing to openly share mistakes.

The investigation team, the nurse who made the mistake, and hospital management were impressed with the process and how TapRooT® helped people focus on what happened and what could be done to improve performance rather than placing blame.

Elaine ShawDirector of Quality Resources, Good Samaritan Hospital

TapRooT® - Changing the Way the World Solves Problems

Root Cause Analysis is a critical part of your management system. TapRooT® was built (and is continuously improved) to help your company meet the ever increasing demands for improved quality of care, patient safety, environmental stewardship, efficiency, regulatory compliance, and employee safety. See how we can help you meet these challenges.

Industries

The TapRooT® System enables companies across a variety of industries to become better at solving problems within their organization. Find out how TapRooT® can be a helpful tool for your company.

Health Care

Recent studies have show that between 100,000 to 200,000 people each year either die or lose significant function because of medical mistakes. Many have shown concern that the standard root cause analysis efforts aren’t improving patient safety. Improving patient safety is an important initiative and advanced root cause analysis (TapRooT®) has an important part to play in saving lives and preventing injuries by finding the fixable causes of human error without placing blame.

Both manufacturing quality and safety are important initiatives in the pharmaceutical industry. TapRooT® can help your company meet strict FDA standards for analysis of out of specification batches, bacterial contamination, mislabeling issues, or drug deterioration while in the supply pipeline. Avoid drug recalls and the black-eye from negative press coverage. In addition, improve safety performance by applying TapRooT® to stop fatalities, significant injuries, and lost time injuries.

Food & Beverage industries face increasing regulatory oversight as a result of food-borne illness that received considerable press coverage. You don’t want your company to be on page one of The Wall Street Journal after an outbreak of listeria or salmonella. TapRooT® can help you analyze the root causes of bacterial contamination or cleanliness issues. In addition, TapRooT® can help you improve your safety performance and prevent serious injuries and fatalities (SIFs) and ergonomic injuries.